Methods and dosing regimens using ibudilast and a second agent for cancer therapy

ABSTRACT

Methods and dosing regimens for treating glioblastoma or recurrent glioblastoma and its associated symptoms by administration of ibudilast (3-isobutyryl-2-isopropylpyrazolo[1,5-a]pyridine) or a pharmaceutically acceptable salt thereof and at least one or more other therapeutic agent.

CROSS-REFERENCE TO RELATED APPLICATION

This application claims the benefit of priority from U.S. ProvisionalPatent Application No. 62/629,579, filed on Feb. 12, 2018, which ishereby incorporated by reference herein in its entirety.

BACKGROUND

The small molecule ibudilast(3-isobutyryl-2-isopropylpyrazolo[1,5-a]pyridine) is an inhibitor ofmacrophage inhibitory factor (MIF) (Cho et al., PNAS-USA 2010 June 107:11313-8), is a selective inhibitor of cyclic nucleotidephosphodiesterases (PDEs) 3A, 4, 10A1 and 11A1 (Gibson et al., Eur. J.Pharmacol. 538: 39-42, 2006), and has toll-like receptor-4 (TLR4)antagonistic activity (Yang et al., Cell Death and Disease (2016) 7,e2234; doi:10.1038/cddis.2016.140). Ibudilast distributes well to theCNS (Sanftner et al., Xenobiotica 2009 39: 964-977) and atclinically-relevant plasma or CNS concentrations, ibudilast selectivelyinhibits macrophage migration inhibitory factor (MIF) and, secondarily,PDEs 3, 4, 10 and 11. Ibudilast also acts as a leukotriene D4antagonist, an anti-inflammatory, a PAF antagonist, and a vasodilatoryagent (Thompson Current Drug Reports). Ibudilast is thought to exert aneuroprotective role in the central nervous system of mammals,presumably via suppression of the activation of glial cells (Mizuno etat, Neuropharmacology 46: 404-411, 2004).

Ibudilast has been widely used in Japan for relieving symptomsassociated with ischemic stroke or bronchial asthma. In recent clinicaltrials, its use in the treatment of multiple sclerosis (MS), aninflammatory disease of the central nervous system, has been explored(News.Medical.Net; Pharmaceutical News, 2 Aug. 2005). As disclosed inthis publication, this clinical trial was expected to treat“relapsing-remitting MS,” however, no mention is made of progressivemultiple sclerosis. In U.S. Pat. No. 6,395,747, ibudilast is disclosedas a treatment for multiple sclerosis, which is generally understood tomean relapsing and remitting multiple sclerosis, not progressivemultiple sclerosis. U.S. Patent Application Publication No. 20060160843discloses ibudilast for the treatment of intermittent and short termpain, however, this is not pain related to a progressiveneurodegenerative disease. However, U.S. Pat. No. 9,314,452 disclosesibudilast as a treatment for amyotrophic lateral sclerosis, aprogressive neurodegenerative disease. Similarly, U.S. Pat. No.8,138,201 discloses ibudilast as a treatment for primary progressivemultiple sclerosis and/or secondary progressive multiple sclerosis.

SUMMARY

In another aspect, provided herein is a method of treating a patientdiagnosed with glioblastoma or suffering from recurrent glioblastomacomprising administering to the patient a therapeutically effectiveamount of ibudilast or a pharmaceutically acceptable salt thereof and atleast one or more other therapeutic agent; wherein ibudilast or apharmaceutically acceptable salt thereof and the at least one or moreother therapeutic agent are administered during an optionally repeatingdosing cycle lasting from about 20 to about 40 days; and wherein the atleast one or more other therapeutic agent is administered during onlythe first about 3 to about 7 days of each dosing cycle. In someembodiments, the at least one or more other therapeutic agent istemozolomide (TMZ), carmustine, bevacizumab, procarbazine, hydroxyurea,irinotecan, lomustine, nimotuzumab, sirolimus, mipsagargin,cabozantinib, lomustine, onartuzumab, patupilone (epothilone B),recombinant oncolytic poliovirus (PVS-RIPO), or any combination of oneor more of the foregoing. In some embodiments, the at least one or moreother therapeutic agent is tetnozolomide (TMZ). In some embodiments,ibudilast or a pharmaceutically acceptable salt thereof and the at leastone or more other therapeutic agent are administered for at least threeconsecutive dosing cycles. In some embodiments, ibudilast or apharmaceutically acceptable salt thereof and the at least one or moreother therapeutic agent are administered for at least six consecutivedosing cycles. In some embodiments, ibudilast or a pharmaceuticallyacceptable salt thereof and the at least one or more other therapeuticagent are administered for at least twelve consecutive dosing cycles. Insome embodiments, ibudilast or a pharmaceutically acceptable saltthereof and the at least one or more other therapeutic agent areadministered for at least twenty-four consecutive dosing cycles. In someembodiments, ibudilast or a pharmaceutically acceptable salt thereof isadministered orally. In some embodiments, ibudilast or apharmaceutically acceptable salt thereof is administered on every day ofthe dosing cycle. In some embodiments, the therapeutically effectiveamount of ibudilast or a pharmaceutically acceptable salt thereof isfrom 0.1 mg to 720 mg per day. In some embodiments, the therapeuticallyeffective amount of ibudilast or a pharmaceutically acceptable saltthereof is from 30 mg to 200 mg per day. In some embodiments, thetherapeutically effective amount of ibudilast or a pharmaceuticallyacceptable salt thereof is about 60 mg per day or about 100 mg per day.In some embodiments, the therapeutically effective amount of ibudilastor a pharmaceutically acceptable salt thereof is administered to thepatient over two equal doses per day. In some embodiments, the at leastone or more other therapeutic agent is administered at a dosage of 0.1mg/(m²⋅day) to 720 mg/(m²⋅day). In some embodiments, the at least one ormore other therapeutic agent is administered at a dosage of 50mg/(m²⋅day) to 250 mg/(m²⋅day). In some embodiments, the at least one ormore other therapeutic agent is administered at a dosage of about 100mg/(m²⋅day), about 150 mg/(m²⋅day) or about 200 mg/(m²⋅day). In someembodiments, ibudilast or a pharmaceutically acceptable salt thereof andthe at least one or more other therapeutic agent are administered for atleast two consecutive dosing cycles; and wherein the at least one ormore other therapeutic agent is administered at a dosage of about 150mg/(m²⋅day) during the first dosing cycle and at a dosage of about 100mg/(m²⋅day), about 150 mg/(m²⋅day) or about 200 mg/(m²⋅day) during thesecond dosing cycle; and wherein during any subsequent dosing cycles,the at least one or more other therapeutic agent is administered at adosage equal to that of the second dosing cycle. In further embodiments,TML is administered orally. In some embodiments, ibudilast or apharmaceutically acceptable salt thereof and the at least one or moreother therapeutic agent are administered for at least two consecutivedosing cycles wherein ibudilast is administered at a dosage of about 60mg per day during the first two dosing cycles. In some embodiments, theglioblastoma is classical glioblastoina, proneural glioblastoma,mesenchymal glioblastoma or neural glioblastoma. In some embodiments,the glioblastoma is classical glioblastoma. In some embodiments, thepatient has extra copies of the epidermal growth factor receptor (EGFR)gene or expresses abnormally high levels of EGFR. In some embodiments,the patient lacks heterozygosity in chromosome 10. In some embodiments,the patient displays chromosome 7 amplification. In some embodiments,the patient has a mutated gene selected from the group consisting ofTP53, PDGFRA, IDH1, PTEN and NF1. In some embodiments, the patientexpresses NEFL, GABRA1, SYT1 or SLC12A5. In some embodiments, thepatient expresses methylated MGMT.

In another aspect, provided herein is a method of treating a patientsuffering from or diagnosed with glioblastoma comprising administeringto the patient a therapeutically effective amount of ibudilast or apharmaceutically acceptable salt thereof. In some embodiments, theibudilast or pharmaceutically acceptable salt thereof is administeredfor at least 3 months. In some embodiments, the ibudilast orpharmaceutically acceptable salt thereof is administered for at leastsix months. In some embodiments, the ibudilast or pharmaceuticallyacceptable salt thereof is administered for at least one year. In someembodiments, the ibudilast or pharmaceutically acceptable salt thereofis administered for at least two years. In some embodiments, theibudilast or pharmaceutically acceptable salt thereof is administered atleast once daily. In some embodiments, the ibudilast or pharmaceuticallyacceptable salt thereof is administered orally. In some embodiments, thetherapeutically effective amount of ibudilast or a pharmaceuticallyacceptable salt thereof is at least 30 mg/day. In some embodiments, thetherapeutically effective amount of ibudilast or a pharmaceuticallyacceptable salt thereof is from 0.1 mg to 720 mg per day. In someembodiments, the therapeutically effective amount of ibudilast or apharmaceutically acceptable salt thereof is from 30 mg to 200 mg perday. In some embodiments, the therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof is 30 mg to 720mg daily. In some embodiments, the therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof is 60 mg to 600mg daily. In some embodiments, the therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof is 100 mg to 480mg daily. In some embodiments, the therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof is selected fromthe group consisting of 30 mg/day, 60 mg/day, 90 mg/day, 120 mg/day, 150mg/day, 180 mg/day, 210 mg/day, 240 mg/day, 270 mg/day, 300 mg/day, 360mg/day, 400 mg/day, 440 mg/day, 480 mg/day, 520 mg/day, 580 mg/day, 600mg/day, 620 mg/day, 640 mg/day, 680 mg/day, and 720 mg/day. In someembodiments, the therapeutically effective amount is administered as asingle dose or is divided into two, three, or four doses. In someembodiments, the ibudilast or a pharmaceutically acceptable salt thereofis administered as part of a combination therapy comprising at least oneadditional therapy. In some embodiments, the at least one additionaltherapy comprises one or more of radiation therapy, one or more othertherapeutic agent, or electric field therapy. In some embodiments, theone or more other therapeutic agent is approved and/or known to have autility in cancer. In some embodiments, the one or more othertherapeutic agent is temozolomide, carmustine, bevacizumab,procarbazine, hydroxyurea, irinotecan, lomustine, nitnotuzurmab,sirolimus, mipsagargin, cabozantinib, lomustine, onartuzumab, patupilone(Epothilone B), recombinant oncolytic poliovirus (PVS-RIPO), or anycombination of one or more of the foregoing. In some embodiments, theone or more other therapeutic agent is temozolomide. Dosing regimens fortemozolomide (TMZ) have been disclosed in the art (see Weller et al.,Standards of care for treatment of recurrent glioblastoma—are we thereyet?, Neuro-Oncology 15(1):4-27 (2013), which is hereby incorporated byreference in its entirety). In some embodiments, the dosing regimen is alow dose TMZ regimen. In some embodiments, the TMZ dose is about 50-100mg/m² for 21 days every 28 days. In some embodiments, the TMZ dose isabout 50-100 mg/m² for 42 days every 70 days. In some embodiments, thedosing regimen is a high dose TMZ regimen. In some embodiments, the TMZdose is about 150-200 mg/m² for 5 days every 28 days. In someembodiments, the ibudilast and TMZ are administered simultaneously. Insome embodiments, the ibudilast and TMZ are administered consecutively.In some embodiments, the ibudilast is administered first followed byTMZ. In some embodiments, the TMZ is administered first followed byibudilast. In some embodiments, ibudilast is administered daily whileTMZ is administered periodically (e.g., every other day, bi weekly,weekly, every other week, etc.). In some embodiments, the at least oneadditional therapy comprises laquinimod. In some embodiments, theibudilast or a pharmaceutically acceptable salt thereof and the at leastone additional therapy are both administered continuously. In someembodiments, the ibudilast or a pharmaceutically acceptable salt thereofis administered continuously and the at least one additional therapy isadministered periodically.

In another aspect, provided herein is a method of treating a patientsuffering from recurrent glioblastoma comprising administering to thepatient a therapeutically effective amount of ibudilast or apharmaceutically acceptable salt thereof. In some embodiments, theibudilast or pharmaceutically acceptable salt thereof is administeredfor at least 3 months. In some embodiments, the ibudilast orpharmaceutically acceptable salt thereof is administered for at leastsix months. In some embodiments, the ibudilast or pharmaceuticallyacceptable salt thereof is administered for at least one year. In someembodiments, the ibudilast or pharmaceutically acceptable salt thereofis administered for at least two years. In some embodiments, theibudilast or pharmaceutically acceptable salt thereof is administered atleast once daily. In some embodiments, the ibudilast or pharmaceuticallyacceptable salt thereof is administered orally. In some embodiments, thetherapeutically effective amount of ibudilast or a pharmaceuticallyacceptable salt thereof is at least 30 mg/day. In some embodiments, thetherapeutically effective amount of ibudilast or a pharmaceuticallyacceptable salt thereof is from 0.1 mg to 720 mg per day. In someembodiments, the therapeutically effective amount of ibudilast or apharmaceutically acceptable salt thereof is from 30 mg to 200 mg perday. In some embodiments, the therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof is 30 mg to 720mg daily. In some embodiments, the therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof is 60 mg to 600mg daily. In some embodiments, the therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof is 100 mg to 480mg daily. In some embodiments, the therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof is selected fromthe group consisting of 30 mg/day, 60 mg/day, 90 mg/day, 120 mg/day, 150mg/day, 180 mg/day, 210 mg/day, 240 mg/day, 270 mg/day, 300 mg/day, 360mg/day, 400 mg/day, 440 mg/day, 480 mg/day, 520 mg/day, 580 mg/day, 600mg/day, 620 mg/day, 640 mg/day, 680 mg/day, and 720 mg/day. In someembodiments, the therapeutically effective amount is administered as asingle dose or is divided into two, three, or four doses. In someembodiments, the ibudilast or a pharmaceutically acceptable salt thereofis administered as part of a combination therapy comprising at least oneadditional therapy. In some embodiments, the at least one additionaltherapy comprises one or more of radiation therapy, one or more othertherapeutic agent, or electric field therapy. In some embodiments, theone or more other therapeutic agent is approved and known to have autility in cancer. In some embodiments, the one or more othertherapeutic agent is temozolomide, carmustine, bevacizurnab,procarbazine, hydroxyurea, irinotecan, lomustine, nimotuzutnab,sirolimus, mipsagargin, cabozantinib, lomustine, onartuzumab, patupilone(Epothilone B), recombinant oncolytic poliovirus (PVS-RIPO), or anycombination of one or more of the foregoing. In some embodiments, theone or more other therapeutic agent is temozolomide. Dosing regimens fortemozolomide (TMZ) have been disclosed in the art (see Weller et al.,Standards of care for treatment of recurrent glioblastoma—are we thereyet?, Neuro-Oncology 15(1):4-27 (2013), which is hereby incorporated byreference in its entirety). In some embodiments, the dosing regimen is alow dose TMZ regimen. In some embodiments, the TMZ dose is about 50-100mg/m² for 21 days every 28 days. In some embodiments, the TMZ dose isabout 50-100 mg/m² for 42 days every 70 days. In some embodiments, thedosing regimen is a high dose TMZ regimen. In some embodiments, the TMZdose is about 150-200 mg/m² for 5 days every 28 days. In someembodiments, the ibudilast and TMZ are administered simultaneously. Insome embodiments, the ibudilast and TMZ are administered consecutively.In some embodiments, the ibudilast is administered first followed byTMZ. In some embodiments, the TMZ is administered first followed byibudilast. In some embodiments, ibudilast is administered daily whileTMZ is administered periodically (e.g., every other day, bi weekly,weekly, every other week, etc.). In some embodiments, the at least oneadditional therapy comprises laquinimod. In some embodiments, theibudilast or a pharmaceutically acceptable salt thereof and the at leastone additional therapy are both administered continuously. In someembodiments, the ibudilast or a pharmaceutically acceptable salt thereofis administered continuously and the at least one additional therapy isadministered periodically.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 is a graphical illustration of the percent survival of the micetreatment groups (ibudilast, temozolomide, or ibudilast andtemozolomide) and the control group post-treatment.

FIG. 2 is a graphical illustration of the percent survival of the miceibudilast treatment groups and the control group post-treatment.

FIG. 3 is a graphical illustration of the percent survival of the micetemozolomide treatment group and the control group post-treatment.

FIG. 4 is a graphical illustration comparing the percent survival of themice treatment combination groups (ibudilast and temozolomide) and thecontrol group post-treatment.

FIG. 5 is a graphical illustration of the percent survival for the micetreatment groups (ibudilast, temozolomide, or ibudilast andtemozolomide) and the control group.

FIG. 6 is a table showing the Schedule of Assessment for human studies.

DETAILED DESCRIPTION

The practice of the present disclosure will employ, unless otherwiseindicated, conventional methods of chemistry, biochemistry, andpharmacology, within the skill of the art. Such techniques are explainedfully in the literature. See, e.g.; A. L. Lehninger, Biochemistry (WorthPublishers, Inc., current addition); Morrison and Boyd, OrganicChemistry (Allyn and Bacon, Inc., current addition); J. March, AdvancedOrganic Chemistry (McGraw Hill, current addition); Remington: TheScience and Practice of Pharmacy, A. Gennaro, Ed., 20th Ed.; FDA'sOrange Book, Goodman & Gilman The Pharmacological Basis of Therapeutics,J. Griffith Hardman, L. L. Limbird, A. Gilman, 11th Ed., 2005, The MerckManual, 18th edition, 2007, and The Merck Manual of Medical information2003.

All publications cited herein, including internet articles, the FDAOrange Book (available on the FDA's website), books, handbooks, journalarticles, patents and patent applications, whether supra or infra, arehereby incorporated by reference in their entirety.

Definitions

Before describing the present disclosure in detail, it is to beunderstood that this disclosure is not limited to particularadministration modes, patient populations, and the like, as such mayvary, as will be apparent from the accompanying description and figures.

It must be noted that, as used in this specification and the intendedclaims, the singular forms “a,” “an,” and “the” include plural referentsunless the context clearly dictates otherwise. Thus, for example,reference to “a drug” includes a single drug as well as two or more ofthe same or different drugs, reference to “an optional excipient” refersto a single optional excipient as well as two or more of the same ordifferent optional excipients, and the like.

In describing and claiming the present disclosure, the followingterminology will be used in accordance with the definitions describedbelow.

As used herein, the term “comprising” or “comprises” is intended to meanthat the compositions and methods include the recited elements, but notexcluding others. “Consisting essentially of” when used to definecompositions and methods, shall mean excluding other elements of anyessential significance to the combination for the stated purpose. Thus,a composition consisting essentially of the elements as defined hereinwould not exclude other materials or steps that do not materially affectthe basic and novel characteristic(s) of the claimed invention.“Consisting of” shall mean excluding more than trace elements of otheringredients and substantial method steps. Embodiments defined by each ofthese transition terms are within the scope of this invention. When anembodiment is defined by one of these terms (e.g., “comprising”) itshould be understood that this disclosure also includes alternativeembodiments, such as “consisting essentially of” and “consisting of” forsaid embodiment.

“Pharmaceutically acceptable excipient or carrier” refers to anexcipient that may optionally be included in the compositions of thedisclosure and that causes no significant adverse toxicological effectsto the patient.

“Pharmaceutically acceptable salt” includes, but is not limited to,amino acid salts, salts prepared with inorganic acids, such as chloride,sulfate, phosphate, diphosphate, bromide, and nitrate salts, or saltsprepared from the corresponding inorganic acid form of any of thepreceding, e.g., hydrochloride, etc., or salts prepared with an organicacid, such as malate, maleate, fumarate, tartrate, succinate,ethylsuccinate, citrate, acetate, lactate, methanesulfonate, benzoate,ascorbate, para-toluenesulfonate, palmoate, salicylate and stearate, aswell as estolate, gluceptate and lactobionate salts. Similarly saltscontaining pharmaceutically acceptable cations include, but are notlimited to, sodium, potassium, calcium, aluminum, lithium, and ammonium(including substituted ammonium).

“Active molecule” or “active agent” as described herein includes anyagent, drug, compound, composition of matter or mixture which providessome pharmacologic, often beneficial, effect that can be demonstratedin-vivo or in vitro. This includes foods, food supplements, nutrients,nutriceuticals, drugs, vaccines, antibodies, vitamins, and otherbeneficial agents. As used herein, the terms further include anyphysiologically or pharmacologically active substance that produces alocalized or systemic effect in a patient. In specific embodiments, theactive molecule or active agent may include ibudilast or apharmaceutically acceptable salt thereof.

“Substantially” or “essentially” means nearly totally or completeinstance, 95%, 96%, 97%, 98%, 99%, or greater of some given quantity.

“Optional” or “optionally” means that the subsequently describedcircumstance may or may not occur, so that the description includesinstances where the circumstance occurs and instances where it does not.

“Glial cells” refer to various cells of the central nervous system alsoknown as microglia, astrocytes, and oligodendrocytes.

The terms “subject”, “individual” or “patient” are used interchangeablyherein and refer to a vertebrate, preferably a mammal. Mammals include,but are not limited to, mice, rodents, rats, simians, humans, farmanimals, dogs, cats, sport animals, and pets.

The terms “pharmacologically effective amount” or “therapeuticallyeffective amount” of a composition or agent, as provided herein, referto a nontoxic but sufficient amount of the composition or agent toprovide the desired response, such as a reduction or reversal ofprogressive neurodegenerative diseases. The exact amount required willvary from subject to subject, depending on the species, age, and generalcondition of the subject, the severity of the condition being treated,the particular drug or drugs employed, mode of administration, and thelike. An appropriate “effective” amount in any individual case may bedetermined by one of ordinary skill in the art using routineexperimentation, based upon the information provided herein.

The term “about” will be understood by persons of ordinary skill in theart and will vary to some extent depending upon the context in which itis used. If there are uses of the term which are not clear to persons ofordinary skill in the art given the context in which it is used, “about”will mean up to plus or minus 10% of the particular term. For example,in some embodiments, it will mean plus or minus 5% of the particularterm. Certain ranges are presented herein with numerical values beingpreceded by the term “about”. The term “about” is used herein to provideliteral support for the exact number that it precedes, as well as anumber that is near to or approximately the number that the termprecedes. In determining whether a number is near to or approximately aspecifically recited number, the near or approximating unrecited numbermay be a number, which, in the context in which it is presented,provides the substantial equivalent of the specifically recited number.

Where a range of values is provided, it is understood that eachintervening value, to the tenth of the unit of the lower limit unlessthe context clearly dictates otherwise, between the upper and lowerlimit of that range and any other stated or intervening value in thatstated range, is encompassed within the invention. The upper and lowerlimits of these smaller ranges may independently be included in thesmaller ranges and are also encompassed within the invention, subject toany specifically excluded limit in the stated range. Where the statedrange includes one or both of the limits, ranges excluding either orboth of those included limits are also included in the disclosure.

As used herein, the term “astrocyte” refers to a specific cell type

As used herein, the terms “glioblastoma multiforme” or “glioblastoma”“or malignant glioma” are well-understood terms in the art. In someembodiments, “glioblastoma multiforme” or “glioblastoma” or “malignantglioma” are used interchangeably herein and refer to a brain tumor thatarises from astrocytes. In some embodiments, glioblastoma is classicalglioblastoma, proneural glioblastoma, mesenchymal glioblastoma or neuralglioblastoma. In some embodiments, glioblastoma is classicalglioblastoma.

As used herein, the term “treatment” or “treating” means any treatmentof a disease or condition or associated disorder, in a patient,including:

-   -   inhibiting the disease or condition, that is, arresting or        suppressing the development of clinical symptoms, such as        cachexia in cancer; and/or    -   relieving the disease or condition that is, causing the        regression of clinical symptoms, e.g., increasing overall        survival or reducing tumor burden.

In some aspects, the term treating refers to an improvement in clinicaloutcomes. The term “clinical outcome” refers to any clinical observationor measurement relating to a patient's reaction to a therapy.Non-limiting examples of clinical outcomes include tumor response (TR),overall survival (OS), progression free survival (PFS), disease freesurvival, time to tumor recurrence (TTR), time to tumor progression(TTP), relative risk (RR), toxicity or side effect. “Overall Survival”(OS) intends a prolongation in life expectancy as compared to naïve oruntreated individuals or patients. “Progression free survival” (PFS) or“Time to Tumor Progression” (TTP) indicates the length of time duringand after treatment that the cancer does not grow. Progression-freesurvival includes the amount of time patients have experienced acomplete response or a partial response, as well as the amount of timepatients have experienced stable disease. “Tumor Recurrence” as usedherein and as defined by the National Cancer Institute is cancer thathas recurred (come back), usually after a period of time during whichthe cancer could not be detected. The cancer may come back to the sameplace as the original (primary) tumor or to another place in the body.It is also called recurrent cancer. “Time to Tumor Recurrence” (TTR) isdefined as the time from the date of diagnosis of the cancer to the dateof first recurrence, death, or until last contact if the patient wasfree of any tumor recurrence at the time of last contact. If a patienthad not recurred, then TTR was censored at the time of death or at thelast follow-up. “Relative Risk” (RR), in statistics and mathematicalepidemiology, refers to the risk of an event (or of developing adisease) relative to exposure. Relative risk is a ratio of theprobability of the event occurring in the exposed group versus anon-exposed group.

“Treatment” or “treating” glioblastoma multiforme (GBM), also known asglioblastoma, or recurrent glioblastoma includes arresting thedevelopment or reversing the symptom or symptoms of glioblastoma and/oran improvement in clinical outcome of the patient suffering fromglioblastotna or recurrent glioblastoma. Non-limiting example ofimprovements in clinical outcome include longer survival time, reductionin tumor size, non-growth in tumor size, and/or lack of exacerbation inneurological symptoms. Non-limiting examples of neurological symptomsinclude double vision, vomiting, loss of appetite, changes in mood andpersonality, changes in ability to think and learn, seizures, speechdifficulty, and cognitive impairment.

Other objects, features and advantages of the present disclosure willbecome apparent from the following detailed description. It should beunderstood, however, that the detailed description and the specificexamples, while indicating specific embodiments of the disclosure, aregiven by way of illustration only, since various changes andmodifications within the spirit and scope of the disclosure will becomeapparent to those skilled in the art from this detailed description.

Ibudilast

The methods of the disclosure for the treatment of glioblastoma orrecurrent glioblastoma are based upon administration of the molecule,ibudilast. Ibudilast is a small molecule drug (molecular weight of230.3) having the structure shown below.

Ibudilast is also found under ChemBank ID 3227, CAS ∩50847-11-5, andBeilstein Handbook Reference No. 5-24-03-00396. Its molecular formulacorresponds to C₁₄H₁₈N₂O. Ibudilast is also known by various chemicalnames including2-methyl-1-(2-(1-methylethyppyrazolo(1,5-a)pyridin-3-yl)1-propanone;3-isobutyryl-2-isopropyl pyrazolo(1,5-a)pyridine]; and1-(2-isopropyl-pyrazolo[1,5-a]pyridin-3-yl)-2-methyl-propan-1-one. Othersynonyms for ibudilast include Ibudilastum (Latin), BRN 0656579, KC-404,and MIN-166. Its brand name is Ketas®, Ibudilast, as referred to herein,is meant to include any and all pharmaceutically acceptable salt formsthereof, prodrug forms (e.g., the corresponding ketal), solvates, andthe like, as appropriate for use in its intended formulation foradministration.

Ibudilast is an inhibitor of the macrophage inhibitory factor (MIF).Ibudilast is also a selective inhibitor of cyclic nucleotidephosphodiesterases (PDEs) 3A, 4. 10A1 and 11A1 (Gibson et al., Eur. J.Pharmacol. 538: 39-42, 2006)., and has also been reported to haveleukotriene D4 and PAF antagonistic activities. Its profile appearseffectively anti-inflammatory and unique in comparison to other PDEinhibitors and anti-inflammatory agents. PDEs catalyze the hydrolysis ofthe phosphoester bond on the 3′-carbon to yield the corresponding5′-nucleotide monophosphate. Thus, they regulate the cellularconcentrations of cyclic nucleotides. Since extracellular receptors formany hormones and neurotransmitters utilize cyclic nucleotides as secondmessengers, the PDEs also regulate cellular responses to theseextracellular signals. There are at least eight classes of PDEs:Ca₂+/calmodulin-dependent PDEs (PDE1); cGMP-stimulated PDEs (PDE2);cGMP-inhibited. PDEs (PDE3); cAMP-specific PDEs (PDE4); cGMP-bindingPDEs (PDE5); photoreceptor PDEs (PDE6); high affinity, cAMP-specificPDEs (PI)E7); and high affinity cGMP-specific PDEs (PDE9). Ibudilastacts to suppress inflammation via action on inflammatory cells (e.g.,glial cells) resulting in the suppression of both pro-inflammatorymediator and neuroactive mediator release. Ibudilast may also suppressthe production of pro-inflammatory cytokines (IL-1β, TNF-α) and mayenhance the production of the anti-inflammatory cytokines (IL-4, IL-10).References related to the foregoing include the following: Obernolte,R., et al, (1993) “The cDNA of a human lymphocyte cyclic-AMPphosphodiesterase (PDE IV) reveals a multigene family” Gene 129:239-247; Rile, G., et al. (2001) “Potentiation of ibudilast inhibitionof platelet aggregation in the presence of endothelial cells” Thromb.Res. 102: 239-246; Souness, J. E., et al. (1994) “Possible role ofcyclic AMP phosphodiesterases in the actions of ibudilast on eosinophilthromboxane generation and airways smooth muscle tone” Br. J. Pharmacol.111: 1081-1088; Suzumura, A., et al. (1999) “lbudilast suppressesTNF.alpha. production by glial cells functioning mainly as type IIIphosphodiesterase inhibitor in CNS” Brain Res. 837: 203-212; Takuma, K.,et al. (2001) “Ibudilast attenuates astrocyte apoptosis via cyclic GMPsignaling pathway in an in vitro reperfusion model” Br. J. Pharmacol.133: 841-848.

The use of rolipram (a PDE4 inhibitor) for treating glioblastoma hasbeen suggested. See Chen et al., Cancer Biol. Ther. 2002, 1(3): 268-276.While rolipram showed positive results in cell assay studies and animalmodel studies, rolipram is not a great candidate for glioblastomatreatment in humans because of its poor penetration into the centralnervous system (CNS). Ibudilast, on the other hand, exhibits good CNSpenetration. (Sanftner et al., Xenobiotica. 2009 39: 964-977).

Without being bound to any one particular theory, the efficacy ofibudilast to treat glioblastoma may not be due to its MIF inhibitoryactivity, but rather due to ibudilast's interaction with other known orunknown targets (such as, but not limited to, one or more PDEs and/orTLR4) along with or regardless of ibudilast's MIF inhibitory activity.

As stated previously, a reference to any one or more of theherein-described drugs, in particular ibudilast, is meant to encompass,where applicable, any and all enantiomers, mixtures of enantiomersincluding racemic mixtures, prodrugs, pharmaceutically acceptable saltforms, hydrates (e.g., monohydrates, dihydrates, etc.), solvates,different physical forms (e.g., crystalline solids, amorphous solids),metabolites, and the like.

Methods of Administration

As set forth above, the present disclosure is directed to a method oftreating a patient, including a human patient, diagnosed withglioblastoma or suffering from recurrent glioblastotna comprisingadministering to the patient a therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof. Suchadministering is effective to decrease the amount of glioblastoma orrecurrent glioblastoma experienced by the patient, i.e., to result in asignificant attenuation or even reversal of glioblastoma or recurrentglioblastoma, as demonstrated in the accompanying Examples. In someembodiments, ibudilast or a pharmaceutically acceptable salt thereof isadministered at a daily dosage amount ranging from about 0.1 mg to 720mg daily, from about 30 mg to 720 mg daily, from about 60 mg to 600 mgdaily, or from about 100 mg to 480 mg daily.

The method of the disclosure may, in certain instances, comprise a stepof selecting a patient experiencing glioblastoma or recurrentglioblastoma prior to administering ibudilast thereto.

Ibudilast or a pharmaceutically acceptable salt thereof may also beadministered as part of a combination therapy comprising at least oneadditional therapy. In some embodiments, the at least one additionaltherapy comprises one or more of radiation therapy, one or more othertherapeutic agent, or electric field therapy.

In some embodiments, the ibudilast or a pharmaceutically acceptable saltthereof and the at least one additional therapy are both administeredcontinuously. In some embodiments, the ibudilast or a pharmaceuticallyacceptable salt thereof is administered continuously and the at leastone additional therapy is administered periodically.

In some embodiments, the one or more other therapeutic agent is approvedand known to have a utility in cancer. In some embodiments, the one ormore other therapeutic agent comprises a phosphodiesterase-3 inhibitor.In some embodiments, the one or more other therapeutic agent comprises aphosphodiesterase-4 inhibitor. In some embodiments, the one or moreother therapeutic agent comprises a macrophage inhibitory factorinhibitor. In some embodiments, the one or more other therapeutic agentcomprises laquinimod. In a preferred embodiment, the one or more othertherapeutic agent possesses a mechanism of action different fromibudilast.

Non-limiting examples of the one or more other therapeutic agent includetemozolomide, carmustine, bevacizumab, procarbazine, hydroxyurea,irinotecan, lomustine, nimotuzumab, sirolimus, mipsagargin,cabozantinib, lomustine, onartuzumab, patupilone (Epothilone B),recombinant oncolytic poliovirus (PVS-RIPO), or any combination of oneor more of the foregoing. In some embodiments, the one or more othertherapeutic agent includes temozolomide.

Preferred methods of delivery of ibudilast-based therapeuticformulations for the treatment of glioblastoma or recurrent glioblastomainclude systemic and localized delivery. Such routes of administrationinclude but are not limited to, oral, intra-arterial, intrathecal,intraspinal, intramuscular, intraperitoneal, intranasal, and inhalationroutes.

More particularly, an ibudilast-based formulation of the presentdisclosure may be administered for therapy by any suitable route,including without limitation, oral, rectal, nasal, topical (includingtransdermal, aerosol, buccal and sublingual), vaginal, parenteral(including subcutaneous, intravenous, intramuscular, and intradermal),intrathecal, and pulmonary. In some embodiments, the ibudilast-basedformulation is administered orally. In some embodiments, theibudilast-based formulation is administered through an injection. Thepreferred route will vary with the condition and age of the recipient,the particular syndrome being treated, and the specific combination ofdrugs employed.

In some embodiments, the ibudilast or pharmaceutically acceptable saltthereof is administered orally. In some embodiments, the ibudilast orpharmaceutically acceptable salt thereof is administered through aninjection.

An ibudilast composition of the disclosure, when comprising more thanone active agent, may be administered as a single combinationcomposition comprising a combination of ibudilast and at least oneadditional active agent effective in the treatment of glioblastoma orrecurrent glioblastoma. In terms of patient compliance and ease ofadministration, such an approach is preferred, since patients are oftenaverse to taking multiple pills or dosage forms, often multiple timesdaily, over the duration of treatment. Alternatively, albeit lesspreferably, the combination of the disclosure is administered asseparate dosage forms. In instances in which the drugs comprising thetherapeutic composition of the disclosure are administered as separatedosage forms and co-administration is required, ibudilast and each ofthe additional active agents may be administered simultaneously,sequentially in any order, or separately.

Dosages

Therapeutic amounts can be empirically determined and will vary with theparticular condition being treated, the subject, and the efficacy andtoxicity of each of the active agents contained in the composition. Theactual dose to be administered will vary depending upon the age, weight,and general condition of the subject as well as the severity of thecondition being treated, the judgment of the health care professional,and particular combination being administered.

Therapeutically effective amounts can be determined by those skilled inthe art, and will be adjusted to the requirements of each particularcase. Generally, a therapeutically effective amount of ibudilast orpharmaceutically acceptable salt thereof will range from a total dailydosage of about 0.1 mg/day to 720 mg/day, about 30-720 mg/day, about60-600 mg/day, or about 100-480 mg/day, or more preferably, in an amountbetween about 1-240 mg/day, about 30-240 mg/day, about 30-200 mg/day,about 30-120 mg/day, about 1-120 mg/day, about 50-150 mg/day, about60-150 mg/day, about 60-120 mg/day, or about 60-100 mg/day, administeredas either a single dosage or as multiple dosages. In some embodiments,the therapeutically effective amount of ibudilast or pharmaceuticallyacceptable salt thereof is from about 30-200 mg/day, administered eitheras a single dosage or as multiple dosages. In some embodiments, multipledosages include two, three, or four doses per day.

Preferred dosage amounts include dosages greater than about 20 mg BID orTID. That is to say, a preferred dosage amount is greater than about 30mg/day, 60 mg/day, 90 mg/day, 120 mg/day, 150 mg/day, 180 mg/day, 210mg/day, 240 mg/day, 270 mg/day, 300 mg/day, 360 mg/day, 400 mg/day, 440mg/day, 480 mg/day, 520 mg/day, 580 mg/day, 600 mg/day, 620 mg/day, 640mg/day, 680 mg/day, and 720 mg/day or more.

In some embodiments, the therapeutically effective amount of ibudilastor pharmaceutically acceptable salt thereof is at least 30 mg/day, atleast 40 mg/day, at least 50 mg/day, at least 60 mg/day, at least 70mg/day, at least 80 mg/day, at least 90 mg/day, at least 100 mg/day, atleast 110 mg/day, at least 120 mg/day, at least 130 mg/day, at least 140mg/day, at least 150 mg/day, at least 160 mg/day, at least 170 mg/day,at least 180 mg/day, at least 190 mg/day, at least 200 mg/day, at least225 mg/day, at least 250 mg/day, at least 275 mg/day, at least 300mg/day, at least 325 mg/day, at least 350 mg/day, at least 375 mg/day,at least 400 mg/day, at least 425 mg/day, at least 450 mg/day, at least475 mg/day, at least 500 mg/day, at least 525 mg/day, at least 550mg/day, at least 575 mg/day, at least 600 mg/day, at least 625 mg/day,at least 650 mg/day, at least 675 mg/day, at least 700 mg/day, or atleast 720 mg/day. In some embodiments, the therapeutically effectiveamount of ibudilast or pharmaceutically acceptable salt thereof is atleast 60 mg/day. In some embodiments, the therapeutically effectiveamount of ibudilast or pharmaceutically acceptable salt thereof is atleast 100 mg/day.

Depending upon the dosage amount and precise condition to be treated,administration can be one, two, three, or four times daily for a timecourse of one day to several days, weeks, months, and even years, andmay even be for the life of the patient. Illustrative dosing regimenswill last a period of at least about a week, from about 1-4 weeks, from1-3 months, from 1-6 months, from 1-52 weeks, from 1-24 months, orlonger. In some embodiments, the ibudilast or the pharmaceuticallyacceptable salt thereof is administered for three months or less. Insome embodiments, the ibudilast or the pharmaceutically acceptable saltthereof is administered for at least three months. In some embodiments,the ibudilast or the pharmaceutically acceptable salt thereof isadministered for at least six months. In some embodiments, the ibudilastor the pharmaceutically acceptable salt thereof is administered for atleast one year. In some embodiments, the ibudilast or thepharmaceutically acceptable salt thereof is administered for at leasttwo years. In some embodiments, the ibudilast or the pharmaceuticallyacceptable salt thereof is administered for at least three years.

In some embodiments, the ibudilast or the pharmaceutically acceptablesalt thereof is administered during repeating dosing cycles lasting fromabout 20 to about 40 days. This includes cycles of lasting from about 20to about 35 days, about 20 to about 30 days, about 25 to about 35 days,and about 25 to about 40 days. In some embodiments, the ibudilast or thepharmaceutically acceptable salt thereof is administered duringrepeating dosing cycles lasting 20, 21, 22, 23, 24, 25, 26, 27, 28, 29,30, 31, 32, 33, 34, 35, 36, 37, 38, 39, or 40 days.

In some embodiments, the ibudilast or the pharmaceutically acceptablesalt thereof is administered during at least 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, or morerepeating dosing cycles. In some embodiments, the ibudilast or thepharmaceutically acceptable salt thereof is administered during 2, 3, 4,5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23,24, or more repeating dosing cycles.

In some embodiments, the ibudilast or the pharmaceutically acceptablesalt thereof is administered during at least 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, or moreconsecutive dosing cycles. In some embodiments, the ibudilast or thepharmaceutically acceptable salt thereof is administered during 2, 3, 4,5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23,24, or more consecutive dosing cycles.

In some embodiments, the ibudilast or the pharmaceutically acceptablesalt thereof is administered during every day of the dosing cycle. Insome embodiments, the ibudilast or the pharmaceutically acceptable saltthereof is not administered during every day of the dosing cycle. Insome embodiments, the ibudilast or the pharmaceutically acceptable saltthereof is administered during every other day of the dosing cycle.

In some embodiments, the therapeutically effective amount of ibudilastor the pharmaceutically acceptable salt thereof is administered in asingle dosage per day. In some embodiments, the therapeuticallyeffective amount of ibudilast or the pharmaceutically acceptable saltthereof is administered in two dosages per day. In some embodiments, thetherapeutically effective amount of ibudilast or the pharmaceuticallyacceptable salt thereof is administered in three dosages per day. Insome embodiments, the therapeutically effective amount of ibudilast orthe pharmaceutically acceptable salt thereof is administered in fourdosages per day. In some embodiments, each of the dosages is equal inthe amount of ibudilast or pharmaceutically acceptable salt thereof thatis administered to the patient. In some embodiments, not each of thedosages is equal in the amount of ibudilast or pharmaceuticallyacceptable salt thereof that is administered to the patient.

In some embodiments, the ibudilast or pharmaceutically acceptable saltthereof is administered at least once daily. In some embodiments, theibudilast or pharmaceutically acceptable salt thereof is administered atleast twice daily.

In some embodiments, the ibudilast is administered as part of acombination therapy comprising at least one additional therapy. In someembodiments, the additional therapy comprises one or more of radiationtherapy, one or more other therapeutic agent, or electric field therapy.In some embodiments, the additional therapy comprises one or more othertherapeutic agents. In some embodiments, the one or more othertherapeutic agent is known to have a utility in cancer. In someembodiments, the one or more other therapeutic agent is temozolomide,carmustine, bevacizumab, procarbazine, hydroxyurea, irinotecan,lomustine, nimotuzumab, sirolimus, mipsagargin, cabozantinib, lomustine,onartuzumab, patupilone (Epothilone B), recombinant oncolytic poliovirus(PVS-RIPO), or any combination of one or more of the foregoing.

In some embodiments, the at least one or more other therapeutic agent isadministered at a dosage of 0.1 mg/(m²⋅day) to 720 mg/(m²⋅day). In someembodiments, the at least one or more other therapeutic agent isadministered at a dosage of 50 mg/(m²⋅day) to 250 mg/(m²⋅day).

In some embodiments, the at least one or more other therapeutic agent isadministered at a dosage of about 100 mg/(m²⋅day), about 150 mg/(m²⋅day)or about 200 mg/(m²⋅day). In some embodiments, the at least one or moreother therapeutic agent is administered at a dosage of about 0.1, 0.2,0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15,20, 25, 30, 35, 40, 45, 50, 60, 70, 80, 90, 100, 120, 125, 140, 150,160, 175, 180, 200, 220, 225, 240, 250, 260, 275, 280, 300, 320, 325,340, 350, 360, 375, 380, 400, 420, 425, 440, 450, 460, 475, 480, 500,520, 525, 540, 550, 560, 575, 580, 600, 620, 625, 640, 650, 660, 675,680, 700, or 720 mg/(m²⋅day). In some embodiments, the ibudilast orpharmaceutically acceptable salt thereof and the at least one or moreother therapeutic agent is administered at the same dosages. In someembodiments, the ibudilast or pharmaceutically acceptable salt thereofand the at least one or more other therapeutic agent is administered atdifferent dosages.

In some embodiments, the at least one or more other therapeutic agent isadministered during every day of the dosing cycle. In some embodiments,the at least one or more other therapeutic agent is administered duringonly certain days of the dosing cycle. In some embodiments, the at leastone or more other therapeutic agent is administered during only thefirst about 3 to about 7 days of the dosing cycle. This includesadministration during the 3, 4, 5, 6, or 7 days of the dosing cycle.

In some embodiments, ibudilast or a pharmaceutically acceptable saltthereof and the at least one or more other therapeutic agent areadministered for at least two consecutive dosing cycles; and wherein theat least one or more other therapeutic agent is administered at a dosageof about 150 mg/(m²⋅day) during the first dosing cycle and at a dosageof about 100 mg/(m²⋅day), about 150 mg/(m²⋅day) or about 200 mg/(m²⋅day)during the second dosing cycle; and wherein during any subsequent dosingcycles, the at least one or more other therapeutic agent is administeredat a dosage equal to that of the second dosing cycle.

In some embodiments, the ibudilast or a pharmaceutically acceptable saltthereof and the at least one or more other therapeutic agent areadministered for at least two consecutive dosing cycles whereinibudilast is administered at a dosage of about 60 mg per day during thefirst two dosing cycles.

In some embodiments, the one or more therapeutic agent is temozolomide(TMZ), Dosing regimens for TMZ in treating glioblastoma have beendisclosed in the art (see Weller et al., Standards of care for treatmentof recurrent glioblastoma—are we there yet?, Neuro-Oncology 15(1):4-27(2013), which is hereby incorporated by reference in its entirety).

In some embodiments, the TML administration is periodic. In someembodiments, TMZ is administered in a repetitive cycle in which TAIL isadministered for a specific period of time, followed bynon-administration of TMZ for a specific period of time.

In some embodiments, the dosing regimen is a low dose TMZ regimen. Insome embodiments, the TMZ dose is about 50-100 mg/m² for 21 days every28 days. This includes 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61,62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79,80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97,98, 99, or 100 mg/m² for 21 days every 28 days. In some embodiments, theTMZ dose is about 50-100 mg/m² for 42 days every 70 days.

In some embodiments, the dosing regimen is a high dose TMZ regimen. Insome embodiments, the TML dose is about 150-200 mg/m² for 5 days every28 days. In some embodiments, the TMZ dose is about 100-200 mg/m² for 5days every 28 days. This includes 100, 101, 102, 103, 104, 105, 106,107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120,121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134,135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145, 146, 147, 148,149, 150, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162,163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176,177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190,190, 191, 192, 193, 194, 195, 196, 197, 198, 199, or 200 mg/m² for 5days every 28 days.

In some embodiments, the ibudilast and TMZ are administeredsimultaneously. In some embodiments, the ibudilast and TMZ areadministered consecutively. In some embodiments, the ibudilast isadministered first followed by TMZ. In some embodiments, the TMZ isadministered first followed by ibudilast.

In some embodiments, ibudilast is administered daily while TMZ isadministered periodically (e.g., every other day, bi weekly, weekly,every other week, etc.) or in a repetitive cycle as discussed above.

Practically speaking, a unit dose of any given composition of thedisclosure or active agent can be administered in a variety of dosingschedules, depending on the judgment of the clinician, needs of thepatient, and so forth. The specific dosing schedule will be known bythose of ordinary skill in the art or can be determined experimentallyusing routine methods. Exemplary dosing schedules include, withoutlimitation, administration five times a day, four times a day, threetimes a day, twice daily, once daily, every other day, three timesweekly, twice weekly, once weekly, twice monthly, once monthly, and soforth.

Treatment of Glioblastoma or Recurrent Glioblastoma

As noted above, in one aspect, the disclosure provides methods fortreating a patient suffering from or diagnosed with glioblastoma orsuffering from or diagnosed with recurrent glioblastoma comprisingadministering to the subject a therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof.

In some embodiments, the patient is a human patient. In someembodiments, the patient has extra copies of the epidermal growth factorreceptor (EGFR) gene or expresses abnormally high levels of EGFR. Insome embodiments, the abnormally high levels of EGRF refers to higherlevels of EGRF in a cancer patient relative to lower levels of EGFR incancer-free individuals. In some embodiments, the patient lacksheterozygosity in chromosome 10. In some embodiments, the patientdisplays chromosome 7 amplification. In some embodiments, the patienthas a mutated gene selected from the group consisting of TP53, PDGFRA,IDH1, PTEN and NF1. In some embodiments, the patient expresses NEFL,GABRA1, SYT1 or SLC12A5.

In some embodiments, the ibudilast or a pharmaceutically acceptable saltthereof is administered as part of a combination therapy comprising atleast one additional therapy. In some embodiments, the at least oneadditional therapy comprises one or more of radiation therapy, one ormore other therapeutic agent, or electric field therapy.

In some embodiments, the one or more other therapeutic agent is approvedor known to have a utility in cancer. In some embodiments, the one ormore other therapeutic agent is temozolomide, carmustine, bevacizumab,procarbazine, hydroxyurea, irinotecan, lomustine, nimotuzumab,sirolitnus, mipsagargin, cabozantinib, lomustine, onartuzumab,patupilone (Epothilone B), recombinant oncolytic poliovirus (PVS-RIPO),or any combination of one or more of the foregoing.

In some embodiments, the one or more other therapeutic agent istemozolomide Dosing regimens for temozolomide (TMZ) have been disclosedin the art (see Weller et al., Standards of care for treatment ofrecurrent glioblastoma—are we there yet?, Neuro-Oncology 15(1)4-27(2013), which is hereby incorporated by reference in its entirety).

In some embodiments, the at least one additional therapy compriseslaquinimod.

In some embodiments, the ibudilast or a pharmaceutically acceptable saltthereof and the at least one additional therapy are both administeredcontinuously. In some embodiments, the ibudilast or a pharmaceuticallyacceptable salt thereof is administered continuously and the at leastone additional therapy is administered periodically.

Animal Models

The ability of ibudilast to treat glioblastoma or recurrent glioblastomacan be evaluated by any of the standard glioblastoma models known in theart. Examples of such models are described in Animal Models ofNeurological Disease: Neurodegenerative Diseases (Neuromethods) by AlanA. Boulton, Glen B. Baker, and Roger F. Butterworth (1992); Handbook ofLaboratory Animal Science, Second Edition: Volumes I-III (Handbook ofLaboratory Animal Science) by Jann Hau (Editor), Jr., Gerald L. VanHoosier (Editor).(2004); Animal Models of Movement Disorders by MarkLeDoux (Editor), (2005); and Animal Models of Cognitive Impairment(Frontiers in Neuroscience) (2006) by Edward D. Levin (Editor), Jerry J.Buccafusco (Editor).

Formulations

In addition to comprising ibudilast or a pharmaceutically acceptablesalt thereof, a therapeutic formulation of the disclosure may optionallycontain one or more additional components as described below.

Excipients/Carriers

In addition to ibudilast or a pharmaceutically acceptable salt thereof,the compositions of the disclosure for treating glioblastoma orrecurrent glioblastoma may further comprise one or more pharmaceuticallyacceptable excipients or carriers. Exemplary excipients include, withoutlimitation, polyethylene glycol (PEG), hydrogenated castor oil (HCO),cremophors, carbohydrates, starches (e.g., corn starch), inorganicsalts, antimicrobial agents, antioxidants, binders/fillers, surfactants,lubricants (e.g., calcium or magnesium stearate), glidants such as talc,disintegrants, diluents, buffers, acids, bases, film coats, combinationsthereof, and the like.

A composition of the disclosure may include one or more carbohydratessuch as a sugar, a derivatized sugar such as an alditol, aldonic acid,an esterified sugar, and/or a sugar polymer. Specific carbohydrateexcipients include for example: monosaccharides, such as fructose,maltose, galactose, glucose, D-mannose, sorbose, and the like;disaccharides, such as lactose, sucrose, trehalose, cellobiose, and thelike; polysaccharides, such as raffinose, melezitose, maltodextrins,dextrans, starches, and the like; and alditols, such as mannitol,xylitol, maltitol lactitol, xylitol, sorbitol (glucitol), pyranosylsorbitol, myoinositol, and the like.

Also suitable for use in the compositions of the disclosure are potatoand corn-based starches such as sodium starch glycolate and directlycompressible modified starch.

Further representative excipients include inorganic salt or buffers suchas citric acid, sodium chloride, potassium chloride, sodium sulfate,potassium nitrate, sodium phosphate monobasic, sodium phosphate dibasic,and combinations thereof.

A composition of the disclosure may also contain one or moreantioxidants, Antioxidants are used to prevent oxidation, therebypreventing the deterioration of the drug(s) or other components of thepreparation. Suitable antioxidants for use in the present disclosureinclude, for example, ascorbyl palmitate, butylated hydroxyanisole,butylated hydroxytoluene, hypophosphorous acid, monothioglycerol, propylgallate, sodium bisulfite, sodium formaldehyde sulfoxylate, sodiummetabisulfite, and combinations thereof.

Additional exemplary excipients include surfactants such aspolysorbates, e.g., “Tween 20” and “Tween 80,” and pluronics such as F68and F88 (both of which are available from BASF, Mount Olive, N.J.),sorbitan esters, lipids (e.g., phospholipids such as lecithin and otherphosphatidylcholines, and phosphatidylethanolamines), fatty acids andfatty esters, steroids such as cholesterol, and chelating agents, suchas EDTA, zinc and other such suitable cations.

Further, a composition of the disclosure may optionally include one ormore acids or bases. Non-limiting examples of acids that can be usedinclude those acids selected from the group consisting of hydrochloricacid, acetic acid, phosphoric acid, citric acid, malic acid, lacticacid, formic acid, trichloroacetic acid, nitric acid, perchloric acid,phosphoric acid, sulfuric acid, fumaric acid, and combinations thereof.Non-limiting examples of suitable bases include, without limitation,bases selected from the group consisting of sodium hydroxide, sodiumacetate, ammonium hydroxide, potassium hydroxide, ammonium acetate,potassium acetate, sodium phosphate, potassium phosphate, sodiumcitrate, sodium formate, sodium sulfate, potassium sulfate, potassiumfumerate, and combinations thereof.

The amount of any individual excipient in the composition will varydepending on the role of the excipient, the dosage requirements of theactive agent components, and particular needs of the composition.Typically, the optimal amount of any individual excipient is determinedthrough routine experimentation, i.e., by preparing compositionscontaining varying amounts of the excipient (ranging from low to high),examining the stability and other parameters, and then determining therange at which optimal performance is attained with no significantadverse effects.

Generally, however, the excipient will be present in the composition inan amount of about 1% to about 99% by weight, preferably from about 5%to about 98% by weight, more preferably from about 15 to about 95% byweight of the excipient. In general, the amount of excipient present inan ibudilast composition of the disclosure is selected from thefollowing: at least about 2%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%,45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or even 95% by weight.

These foregoing pharmaceutical excipients along with other excipientsare described in “Remington: The Science & Practice of Pharmacy”, 19thed., Williams & Williams, (1995), the “Physician's Desk Reference”,52.sup.nd ed., Medical Economics, Montvale, N.J. (1998), and Kibbe, A.H., Handbook of Pharmaceutical Excipients, 3.sup.rd Edition, AmericanPharmaceutical Association, Washington, D.C., 2000.

Other Actives

A formulation (or kit) in accordance with the disclosure may contain, inaddition to ibudilast or a pharmaceutically acceptable salt thereof, oneor more other therapeutic active agent effective in treatingglioblastoma or recurrent glioblastoma. In some embodiments, the one ormore other therapeutic agent comprises a phosphodiesterase-3 inhibitor.In some embodiments, the one or more other therapeutic agent comprises aphosphodiesterase-4 inhibitor. In some embodiments, the one or moreother therapeutic agent comprises a macrophage inhibitory factorinhibitor. In some embodiments, the one or more other therapeutic agentcomprises laquinimod. In a preferred embodiment, the one or more othertherapeutic agent possesses a mechanism of action different fromibudilast.

Preferably, the one or more other therapeutic agent is one thatpossesses a mechanism of action different from that of ibudilast. Suchactive ingredients can be found listed in the FDA's Orange Book, Goodman& Gilman The Pharmacological Basis of Therapeutics, J. Griffith Hardman,L. L. Limbird, A. Gilman, 11th Ed., 2005, The Merck Manual, 18thedition, 2007, and The Merck Manual of Medical Information 2003.

The dosage amounts provided above are meant to be merely guidelines; theprecise amount of a secondary active agent to be administered duringcombination therapy with ibudilast or the pharmaceutically acceptablesalt thereof will, of course, be adjusted accordingly and will dependupon factors such as intended patient population, the particularprogressive neuropathic disease symptom or condition to be treated,potential synergies between the active agents administered, and thelike, and will readily be determined by one skilled in the art basedupon the guidance provided herein.

Sustained Delivery Formulations

Preferably, the compositions are formulated in order to improvestability and extend the half-life of ibudilast or the pharmaceuticallyacceptable salt thereof. For example, ibudilast or the pharmaceuticallyacceptable salt thereof may be delivered in a controlled orextended-release formulation. Controlled or extended-releaseformulations are prepared by incorporating ibudilast or thepharmaceutically acceptable salt thereof into a carrier or vehicle suchas liposomes, nonresorbable impermeable polymers such as ethylenevinylacetate copolymers and Hytrel® copolymers, swellable polymers such ashydrogels, or resorbable polymers such as collagen and certain polyacidsor polyesters such as those used to make resorbable sutures.Additionally, ibudilast or the pharmaceutically acceptable salt thereofcan be encapsulated, adsorbed to, or associated with, particulatecarriers. Examples of particulate carriers include those derived frompolymethyl methacrylate polymers, as well as microparticles derived frompoly(lactides) and poly(lactide-co-glycerides), known as PLG. See, e.g.,Jeffery et al., Pharm. Res. (1993) 10:362-368; and McGee et al., J.Microencap. (1996).

Extended release polymers suitable for this purpose are known in the artand include hydrophobic polymers such as cellulose ethers. Non-limitingexamples of suitable cellulose ethers include ethyl cellulose, celluloseacetate and the like; polyvinyl esters such as polyvinyl acetate,polyacrylic acid esters, methacrylic and acrylate polymers(pH-independent types); high molecular weight polyvinyl alcohols andwaxes such as fatty acids and glycerides, methacrylic acid ester neutralpolymers, polyvinyl alcohol-maleic anhydride copolymers and the like;ethylacrylate-methylmethacrylate copolymers; aminoalkyl methacrylatecopolymers; and mixtures thereof.

Delivery Forms

The ibudilast or pharmaceutically acceptable salt thereof compositionsdescribed herein encompass all types of formulations, and in particular,those that are suited for systemic or intrathecal administration. Oraldosage forms include tablets, lozenges, capsules, syrups, oralsuspensions, emulsions, granules, and pellets. In some embodiments, theoral dosage form is a tablet. In some embodiments, the tablet is anextended release tablet. In some embodiments, the oral dosage form is acapsule. In some embodiments, the capsule is an extended releasecapsule.

Alternative formulations include aerosols, transdermal patches, gels,creams, ointments, suppositories, powders or lyophilates that can bereconstituted, as well as liquids. Examples of suitable diluents forreconstituting solid compositions, e.g., prior to injection, includebacteriostatic water for injection, dextrose 5% in water,phosphate-buffered saline, Ringer's solution, saline, sterile water,deionized water, and combinations thereof. With respect to liquidpharmaceutical compositions, solutions and suspensions are envisioned.Preferably, an ibudilast or pharmaceutically acceptable salt thereofcomposition of the disclosure is one suited for oral administration.

In turning now to oral delivery formulations, tablets can be made bycompression or molding, optionally with one or more accessoryingredients or additives. Compressed tablets are prepared, for example,by compressing in a suitable tabletting machine, the active ingredientsin a free-flowing form such as a powder or granules, optionally mixedwith a binder (e.g., povidone, gelatin, hydroxypropylmethyl cellulose),lubricant, inert diluent, preservative, disintegrant (e.g., sodiumstarch glycolate, cross-linked povidone, cross-linked sodiumcarboxymethyl cellulose) and/or surface-active or dispersing agent.

Molded tablets are made, for example, by molding in a suitabletabletting machine, a mixture of powdered compounds moistened with aninert liquid diluent. The tablets may optionally be coated or scored,and may be formulated so as to provide slow or controlled release of theactive ingredients, using, for example, hydroxypropylmethyl cellulose invarying proportions to provide the desired release profile. Tablets mayoptionally be provided with a coating, such as a thin film, sugarcoating, or an enteric coating to provide release in parts of the gutother than the stomach. Processes, equipment, and toll manufacturers fortablet and capsule making are well-known in the art.

Formulations for topical administration in the mouth include lozengescomprising the active ingredients, generally in a flavored base such assucrose and acacia or tragacanth and pastilles comprising the activeingredients in an inert base such as gelatin and glycerin or sucrose andacacia.

A pharmaceutical composition for topical administration may also beformulated as an ointment, cream, suspension, lotion, powder, solution,paste, gel, spray, aerosol or oil.

Alternatively, the formulation may be in the form of a patch (e.g., atransdermal patch) or a dressing such as a bandage or adhesive plasterimpregnated with active ingredients and optionally one or moreexcipients or diluents. Topical formulations may additionally include acompound that enhances absorption or penetration of the ingredientsthrough the skin or other affected areas, such as dimethylsulfoxidembisabolol, oleic acid, isopropyl myristate, and D-limonene, to name afew.

For emulsions, the oily phase is constituted from known ingredients in aknown manner. While this phase may comprise merely an emulsifier(otherwise known as an emulgent), it desirably comprises a mixture of atleast one emulsifier with a fat and/or an oil. Preferably, a hydrophilicemulsifier is included together with a lipophilic emulsifier that actsas a stabilizer. Together, the emulsifier(s) with or withoutstabilizer(s) make up the so-called emulsifying wax, and the waxtogether with the oil and/or fat make up the so-called emulsifyingointment base which forms the oily dispersed phase of creamformulations. Illustrative emulgents and emulsion stabilizers includeTween 60, Span 80, cetostearyl alcohol, myristyl alcohol, glycerylmonostearate and sodium lauryl sulfate.

Formulations for rectal administration are typically in the form of asuppository with a suitable base comprising, for example, cocoa butteror a salicylate.

Formulations suitable for vaginal administration generally take the formof a suppository, tampon, cream, gel, paste, foam or spray.

Formulations suitable for nasal administration, wherein the carrier is asolid, include a coarse powder having a particle size, for example, inthe range of about 20 to about 500 microns. Such a formulation istypically administered by rapid inhalation through the nasal passage,e.g., from a container of the powder held in proximity to the nose.Alternatively, a formulation for nasal delivery may be in the form of aliquid, e.g., a nasal spray or nasal drops.

Aerosolizable formulations for inhalation may be in dry powder form(e.g., suitable for administration by a dry powder inhaler), or,alternatively, may be in liquid form, e.g., for use in a nebulizer.Nebulizers for delivering an aerosolized solution include the AERx®(Aradigm), the Ultravent® (Mallinkrodt), and the Acorn II® (MarquestMedical Products). A composition of the disclosure may also be deliveredusing a pressurized, metered dose inhaler (MDI), e.g., the Ventolin®metered dose inhaler, containing a solution or suspension of acombination of drugs as described herein in a pharmaceutically inertliquid propellant, e.g., a chlorofluorocarbon or uorocarbon.

Formulations suitable for parenteral administration include aqueous andnon-aqueous isotonic sterile solutions suitable for injection, as wellas aqueous and non-aqueous sterile suspensions.

Parenteral formulations of the disclosure are optionally contained inunit-dose or multi-dose sealed containers, for example, ampoules andvials, and may be stored in a freeze-dried (lyophilized) conditionrequiring only the addition of the sterile liquid carrier, for example,water for injections, immediately prior to use. Extemporaneous injectionsolutions and suspensions may be prepared from sterile powders, granulesand tablets of the types previously described.

A formulation of the disclosure may also be an extended releaseformulation, such that each of the drug components is released orabsorbed slowly over time, when compared to a non-sustained releaseformulation. Sustained release formulations may employ pro-drug forms ofthe active agent, delayed-release drug delivery systems such asliposomes or polymer matrices, hydrogels, or covalent attachment of apolymer such as polyethylene glycol to the active agent.

In addition to the ingredients particularly mentioned above, theformulations of the disclosure may optionally include other agentsconventional in the pharmaceutical arts and particular type offormulation being employed, for example, for oral administration forms,the composition for oral administration may also include additionalagents as sweeteners, thickeners or flavoring agents.

Kits

Also provided herein is a kit containing at least one combinationcomposition of the disclosure, accompanied by instructions for use.

For example, in instances in which each of the drugs themselves areadministered as individual or separate dosage forms, the kit comprisesibudilast in addition to each of the drugs making up the composition ofthe disclosure, along with instructions for use. The drug components maybe packaged in any manner suitable for administration, so long as thepackaging, when considered along with the instructions foradministration, clearly indicates the manner in which each of the drugcomponents is to be administered.

For example, for an illustrative kit comprising ibudilast andgabapentin, the kit may be organized by any appropriate time period,such as by day. As an example, for Day 1, a representative kit maycomprise unit dosages of each of ibudilast and gabapentin. If each ofthe drugs is to be administered twice daily, then the kit may contain,corresponding to Day 1, two rows of unit dosage forms of each ofibudilast and gabapentin, along with instructions for the timing ofadministration. Alternatively, if one or more of the drugs differs inthe timing or quantity of unit dosage form to be administered incomparison to the other drug members of the combination, then such wouldbe reflected in the packaging and instructions. Various embodimentsaccording to the above may be readily envisioned, and would of coursedepend upon the particular combination of drugs, in addition toibudilast, employed for treatment, their corresponding dosage forms,recommended dosages, intended patient population, and the like. Thepackaging may be in any form commonly employed for the packaging ofpharmaceuticals, and may utilize any of a number of features such asdifferent colors, wrapping, tamper-resistant packaging, blister packs,dessicants, and the like.

It is to be understood that while the disclosure has been described inconjunction with preferred specific embodiments, the foregoingdescription as well as the examples that follow are intended toillustrate and not limit the scope of the disclosure. Other aspects,advantages and modifications within the scope of the disclosure will beapparent to those skilled in the art to which the disclosure pertains.

All references mentioned in this application, including any patents,published patent applications, books, handbooks, journal publications,or the FDA Orange Book are hereby incorporated by reference herein, intheir entirety.

The following examples are given for the purpose of illustrating variousembodiments of the disclosure and are not meant to limit the presentdisclosure in any fashion. One skilled in the art will appreciatereadily that the present disclosure is well adapted to carry out theobjects and obtain the ends and advantages mentioned, as well as thoseobjects, ends and advantages inherent herein. The present examples,along with the methods described herein are presently representative ofembodiments and are exemplary, and are not intended as limitations onthe scope of the disclosure. Changes therein and other uses which areencompassed within the spirit of the disclosure as defined by the scopeof the claims will occur to those skilled in the art.

EXAMPLES Example 1 Ibudilast and Temozolomide Efficacy in Balb/c NudeMice Harboring Patient Derived Glioblastoma

Patient-derived cell line RN1 (2 μL) was intra-cranially injected intobalb/c nude mice. The RN1 cell line was chosen because it isO(6)-methylguanine-DNA methyltransferase (MGMT) unmethylated andtypically resistant to treatment with TMZ.

Once the balb/c nude mice arrived, they were allowed to acclimate totheir new environment and the study participants for a period of 10days. Mice were housed in groups of 4, and unless undergoing aprocedure, were given free access to food and water at all times.

Individual mice were identified via a unique ear punch number. Astandard numbering system was used in which a specific ear punchlocation was associated with its own number.

Tumor Implantation

6-8 week old balbic nude mice were used. All procedures, exceptautopsies, were carried out within a laminar flow cabinet. Tumors wereinduced following the procedure disclosed in Wakimoto H. et al, (2012)Neuro Oncol. 14(2): 132-44. Balb/c nude mice were weighed and held ingroups of four. The mice received an analgesic 2 hours prior to primaryhuman tumor cell implantation—the mice were injected subcutaneously with5 mg/kg Rimadyl (Carprofen). The animals were anesthetized viacontinuous mask inhalation of isoflurane (2.5-3%, IL/min oxygen forinduction and 1-2.5%, 0.2 L/min oxygen for maintenance). The depth ofanesthesia was assessed by toe pinch reflex (leg withdrawal before theprocedure began (cf. monitoring sheet #1).

Using a number 11 scalpel blade, the skin on the head was cut sagittally(approximately from the level of the ears to the front of the eyes).This incision was large enough to allow identification of skulllandmarks and prevent retracted skin from getting in the way ofdrilling. Using a stereotactic frame (small animal stereotactic frame,David KOH Instruments, Germany), the head was clamped firmly in positionby placing the side clamps on the bone approximately between the eyesand ears. These clamps not only functioned to keep the head from movingduring the procedure (due to normal breathing) but also to kept theretracted skin in place so the skull remained accessible.

A 2 mm drill hole was made at the stereotactically in the right caudateputamen using the coordinates 1 mm anterior, 1.5 mm lateral, and 3.0 mmbelow the bregma. A micro-injector unit (holding a 2 μl Hamilton syringewith a 25-gauge needle) connected to the manipulating arm of thestereotactic device was used to inject a 2 μL solution containing200,000 primary human tumor cells dorsoventrally (DV) at −3 from theskull surface, to deposit cells into the lateral portion of the striatum(right basal ganglia). All injections were made over a period of 10minutes to ensure optimal parenchymal compliance. The micro-injectorneedle was retracted and the burr hole in the skull closed usingbone-wax (Johnson & Johnson) in order to prevent extracranial tumorgrowth. Skin was closed using a tissue adhesive (Vetbond). Mice receivedsterile eye drops (Systane) throughout the procedure to avoid eyedryness.

The total duration of the implantation procedure was approximately 35minutes. The whole procedure was performed above a thermostaticallycontrolled warming pad to prevent a drop in animal temperature duringsurgery.

Post-surgical animals were moved to the recovery area, placed on beddingwithin an animal box, warmed using a small animal infrared heat lamp,and were monitored until they woke up, at which time they were returnedto their housing (cf monitoring sheet #1). Heat lamps were used insteadof thermostatic controlled warming pads, as these pads were not able tosufficiently warm the mice through the floor of the animal box, whichwas used to keep the mice in a sterile environment while they recoverfrom surgery. To prevent the mice from overheating, the temperatureinside the box was monitored using a standard thermometer.

Treatment

Ibudilast

Two dosages of ibudilast were administered to the balb/c nude mice: 5mg/kg and 20 mg/kg (both in 100 μL total volume). The dosage ofibudilast was extrapolated from multiple animal studies on rats lookingat the treatment of multiple sclerosis (MS) disease and models ofcentral neuropathic pain (Ellis et al. 2014; Reagan-shave et al. 2008).Ibudilast showed no toxicity and was administered via gavage.

Temozolomide

10 mg/kg of temozolomide (TMZ) was administered to the balb/c nude micethrough intraperitoneal injection.

RN1 (MGMT unmethylated GBM)-Injected Balb/c Nude Mice

Five treatment groups were used as follows:

1. ibudilast 5 mg/kg by gavage (n=8)

2. Ibudilast: 20 mg/kg by gavage (n=8)

3. Combination 1: Ibudilast (5 mg/kg)+TMZ (10 mg/kg) (n=8)

4. Combination 2: Ibudilast (20 mg/kg)+TMZ (10 mg/kg) (n=8)

5. Control saline containing polyoxyethylene hydrogenated castor oil 60;100 μL) (n=8)

For all of the treatment groups (except the control group), ibudilastwas administered by gavage (daily) for approximately 59 days (until thelast control mouse died) and TMZ was administered via intraperitonealinjection (daily) for two weeks.

Each treatment group contained eight animals. Approximately two animalsfrom each control group were humanely euthanized at Day 40, Day 45, Day50, and Day 60 in order to monitor tumor growth. This was becausemagnetic resonance imaging (MRI) is not sensitive enough to detect thetumor in vivo and there are no other means to detect the presence of thetumor other than humanely euthanizing the mice, removing the brain,fixing in paraffin and then sectioning the brain and staining withhaemotoxylin and eosin (H&E). Upon confirmation that the tumor waspresent, the treatments were immediately started.

Tissue was collected from all animals at end points and biomarkeranalysis was conducted.

At approximately 43 days after tumor implantation, mice were treatedwith temozolomide (10 mg/kg) and/or ibudilast (5 mg/kg or 20 mg/kg).Ibudilast was administered in a solution of saline containingpolyoxyethylene hydrogenated castor oil 60 using the gavage method (100μl total volume) (Fujimoto et al., 1999 J Neuroimmunology 95:1-2,35-42). Temozolomide was delivered by intraperitoneal injection (I.P.)in 0.1% dimethyl sulfoxide (DMSO, 100 μl total volume).

Monitoring

The body weight of each animal was measured twice a week in addition toroutine daily monitoring by animal house staff (cf monitoring sheet #2).

The animals started to lose 5-10% of their body weight the week beforethe appearance of neurological decline. At this particular time, animalswere carefully monitored (twice daily) as neurological decline can occurrapidly. Typical signs of neurological decline include a hunched posturewith an arched back, continuous circling, walking on tip-toes, balanceissues, closed eyes, hyperactivity, and seizures. Neurological declinewas scored (cf. monitoring sheet 43) for each animal.

Euthanasia

When signs of pain, distress or neurological decline were noted, animalswere immediately euthanized by inhalation of a progressive overdose ofcarbon dioxide (cf. B.7). Animals were also immediately euthanized ifthey lost more than 20% of their body weight. If these signs were notobserved, mice were euthanized by a progressive overdose of carbondioxide no later than 260 days (37 weeks) following tumor induction.

When animals were euthanized, their brains were harvested and tumorswere processed for immunohistochemical examination, molecular typing andpreparation of cell stocks. Kaplan-Meier analysis was used to estimatesurvival from tumor induction.

Results

In all groups, the treatment of ibudilast alone or ibudilast incombination with temozolomide was well tolerated. The median survival ofthe untreated mice was 100.5 days. The medial survival time of theibudilast 5 mg/kg and TMZ combination group was 114 days. The mediansurvival time of the ibudilast 20 mg/kg and TMZ combination group was111.5 days. Additionally, one mouse in the ibudilast 5 mg/kg group andtwo mice in the ibudilast 20 mg/kg group survived longer than thelongest surviving mouse in the control group.

All the mice in the control group died within 105 days (0% survivalrate). At 105 days, the ibudilast 5 mg/kg group exhibited a 12% survivalrate (one out of eight mice); the ibudilast 20 mg/kg group exhibited a25% survival rate (two out of eight mice); the ibudilast 5 mg/kg and TMZcombination group exhibited a 65.5% survival rate (five out of eightmice); and the ibudilast 20 mg/kg and TMZ combination group exhibited a50% survival rate (four out of eight mice) (see FIG. 1).

The median survival times for mice treated with ibudilast as amonotherapy did not significantly differ from the controls at either lowdose (5 mg/kg) or high dose (20 mg/kg) ibudilast (89 and 97.5 days,respectively) (see FIG. 2). Treatment with TMZ (10/mg/kg) resulted in asurvival advantage when compared to control mice (100.5 days versus105.5 days) (LogRank p=0.0547) (see FIG. 3). The higher dose tested, 20mg/kg ibudilast, when combined with 10 mg/kg TMZ, was not significantlygreater than the lower dose of ibudilast. Significant survivaladvantages were observed for both combination groups (ibudilast 5 mg/kgand TMZ and ibudilast 20 mg/kg and TMZ) (see FIG. 4). There was nosignificant difference between the two doses of ibudilast when combinedwith TMZ. FIG. 5 illustrates the survival proportions in control micecompared to ibudilast (5 mg/kg), TMZ alone, and combination treatment(ibudilast 5 mg/kg+TMZ 10 mg/kg).

These results demonstrate that ibudilast has a positive effect in themouse glioblastoma model and that, the ibudilast effect is dosedependent (20 mg/kg was more effective than 5 mg/kg), indicating thatibudilast may be effective for treating glioblastoma or recurrentglioblastoma. Additionally, the ibudilast effect was more evident forthe combination of ibudilast and TMZ, indicating that ibudilast and TMZin combination may be effective for treating glioblastoma or recurrentglioblastoma.

Example 2 Ibudilast and Temozoininide Efficacy in Balb/c Nude MiceHarboring Patient Derived Glioblastoma

The same protocol is used as in Example 1 except the HW1 cell line isused instead of the RN1 cell line. The HW1 cell line is MGMT methylatedand is susceptible to much lower levels of TMZ.

Similar results are shown as seen in Example 1, confirming thatibudilast and TMZ in combination may be effective for treatingglioblastoma or recurrent glioblastoma.

Example 3 Human Studies (Ibudilast Only)

This is a single-center, open-label study to evaluate safety,tolerability and efficacy of ibudilast with recurrent grade 4glioblastoma as adjunctive therapy. The duration of this study is oneyear. Ibudilast up to 100 mg/day is orally administered twice a day over52 weeks in human subjects with confirmed grade 4 recurrent glioblastomaper brain MRI. Up to five patients are enrolled. Eligible subjects willconsist of males and females age 18 or above. The study consists of aScreening Phase followed by a Treatment Phase (52 weeks), and aFollow-up Visit (within 4 weeks after the last dose).

Efficacy Points

The primary efficacy point is to evaluate the safety and tolerability ofibudilast as an adjunctive therapy for recurrent glioblastoma. Thesecondary efficacy point is to obtain pilot data on the efficacy ofibudilast as an adjunctive therapy of recurrent glioblastoma. MRI(Magnetic Resonance Imaging) is used to measure changes in brain tumorsize (cm²). Survival time is assessed in addition to the time tocerebral edema requiring steroid rescue treatment.

Safety Endpoints

The proportion of subjects with:

-   -   Treatment-emergent adverse events (TEAEs)    -   Treatment-emergent serious adverse events (TESAEs)    -   Treatment discontinuations due to treatment-emergent adverse        events

Additional Safety Endpoints

Laboratory measures (chemistry, hematology, urinalysis), vital signs,and 12 lead-electrocardiograms (ECGs).

Screening: Phase

During the Screening Phase, subjects are assessed for study eligibility.The following assessments are performed: medical history includingreview of prior medications, physical examination including height andbody weight, vital signs and an electrocardiogram. Other assessmentsinclude clinical labs, chemistry (including liver enzymes, gammaglutamyl transferase, etc.), hematology, urinalysis and a serumpregnancy test.

Inclusion Criteria

1. Age 18 or above

2. Ability and willingness to signed informed consent form

3. Grade 4 GBM (glioblastoma multiforme), GBM. histologically confirmed,World Health Organization (WHO) criteria

4. Confirmed overexpression of macrophage inhibitory factor (MIF)/CD74in GBM cell

5. Documented recurrence or progression after surgicalresection/debulking, radiation and temozolomide chemotherapy.

6. Measurable contrast-enhancing progressive or recurrent GBM by MRIimaging before screening

Exclusion Criteria

1. Acute intracranial or intra-tumoral hemorrhage>Grade 1 either by MRIor CT scan ≤2 weeks of screening (subjects with resolving hemorrhagechanges, punctate hemorrhage, or hemosiderin may enter the study)

2. Any significant laboratory abnormality which may put the subject atrisk and with the following laboratory abnormalities at screening:

-   -   Creatinine >1.7 mg/dL    -   WBCs <3,000 mm³    -   Lymphocytes <800 mm³    -   Platelets <90,000 mm³

3. Anticoagulation treatment with ≥1 mg/day coumadin ≤7 days prior toscreening (low-dose [≤1 mg/day] coumadin, heparin, andlow-molecular-weight heparin are permitted

4. Any systemic illness or unstable medical condition that might poseadditional risk, including: cardiac, unstable metabolic or endocrinedisturbances, renal or liver disease, past history of renal calculi,hyperuricemia, hypercalcemia, mitochondrial disease, known disorder offatty acid metabolism, porphyria, carnitine deficiency and pancreatitis

5. History of non-glioma malignancy other than:

-   -   Surgically excised non-melanoma skin cancer or in situ carcinoma        of the cervix.    -   A malignancy diagnosed years ago if the subject has had no        evidence of disease for 2 years prior to screening.

6. Active drug or alcohol dependence or any other factors that, in theopinion of the site investigators would interfere with adherence tostudy requirements

7. History of human immunodeficiency virus, or hepatitis C

8. Failure to recover from <Common Terminology Criteria for AdverseEvents (CTCAE) grade 2 toxicities related to prior therapy

9. Pregnancy or breastfeeding

10. Use of any investigational drug within 1 month of enrollment

Treatment Phase (52 Weeks)

Subjects who complete all of the screening assessments and meet allinclusion/exclusion criteria return to the clinic on Treatment Day 1 toreceive their first dose. Subjects are started on MN-166 30 mg BID. Thedosage for the first two weeks is 30 mg BID and is subsequently titratedup to 50 mg BID, if tolerated. Afterwards, subjects return to the clinicon a regular basis (see FIG. 2, Schedule of Assessments) for 52 weeks.During the Treatment Phase, safety and efficacy parameters are assessedand concomitant medications are documented.

Individual Stopping Criteria

Subjects who experience an adverse event of Grade 2 nausea and/ordiarrhea for greater than three consecutive days or Grade 3 nauseaand/or vomiting for greater than one day thought to be related toibudilast are discontinued from the study. Additionally, subjects whoexperience an adverse event of Grade 3 abdominal pain lasting forgreater than one day thought to be related to ibudilast are discontinuedfrom the study.

Study Stopping Rules

The study is stopped if two subjects experience a Grade 4 adverse eventthought to be related to ibudilast.

Follow-Up Phase

All subjects who complete the study return for a follow-up visit (within4 weeks from last dose) to assess adverse event status and to documentconcomitant medications.

Example 4 Human Studies (Ibudilast and TMZ)

GBM is treated via administering ibudilast and TMZ over the course of a28 day dosing cycle. TMZ is administered on days 1-5 of the 28-day cycle(at a dosage of 100, 150 or 200 mg/(m²*day)) or on days 1-21 of the28-day cycle (at a dosage of 75 mg/(m¹*day)). Treatment may compriseconsecutive cycles.

Ibudilast is administered at the same dose throughout a dose cycle. Dosecohorts possible are 60 mg per day (30 mg b.i.d.) or 100 mg (50 mg eachb.i.d.). Ibudilast is administered at a dosage of 40 mg per day (20 mgb.i.d.) if the 60 mg per day dose is not well tolerated.

Patient blood is collected before and after treatment for evaluation ofMDSCs, regulatory 17-cells, and CD4-+ T-cells.

Progression free survival and overall survival of the patients isassessed.

Equivalents

It should be understood that although the present disclosure has beenspecifically disclosed by certain embodiments and optional features,modification, improvement and variation of the disclosures embodieddisclosed herein may be resorted to by those skilled in the art, andthat such modifications, improvements and variations are considered tobe within the scope of this disclosure. The materials, methods, andexamples provided here are representative of certain embodiments, areexemplary, and are not intended as limitations on the scope of thedisclosure.

The disclosure has been described broadly and generically herein. Eachof the narrower species and subgeneric groupings falling within thegeneric disclosure also form part of the disclosure. This includes thegeneric description of the disclosure with a proviso or negativelimitation removing any subject matter from the genus, regardless ofwhether or not the excised material is specifically recited herein.

In addition, where features or aspects of the disclosure are describedin terms of Markush groups, those skilled in the art, will recognizethat the disclosure is also thereby described in terms of any individualmember or subgroup of members of the Markush group.

The use of the term “or” in the claims is used to mean “and/or” unlessexplicitly indicated to refer to alternatives only or the alternativesare mutually exclusive, although the disclosure supports a definitionthat refers to only alternatives and “and/or.”

Para. A. A method of treating a patient diagnosed with glioblastoma orsuffering from recurrent glioblastoma comprising:

-   -   administering to the patient a therapeutically effective amount        of ibudilast or a pharmaceutically acceptable salt thereof and        at least one or more other therapeutic agent;    -   wherein ibudilast or a pharmaceutically acceptable salt thereof        and the at least one or more other therapeutic agent are        administered during an optionally repeating dosing cycle lasting        from about 20 to about 40 days;    -   and wherein the at least one or more other therapeutic agent is        administered during only the first about 3 to about 7 days of        each dosing cycle.

Para. B. The method of Para. A, wherein the at least one or more othertherapeutic agent is temozolomide (TMZ), carmustine, bevacizumab,procarbazine, hydroxyurea, irinotecan, lomustine, nimotuzumab,sirolimus, mipsagargin, cabozantinib, lomustine, onartuzumab, patupilone(epothilone B), recombinant oncolytic poliovirus (PVS-RIPO), or anycombination of one or more of the foregoing.

Para. C. The method of Para. A or Para. B, wherein the at least one ormore other therapeutic agent is temozolomide (TMZ).

Para. D. The method of any one of Paras. A-C, wherein ibudilast or apharmaceutically acceptable salt thereof and the at least one or moreother therapeutic agent are administered for at least three consecutivedosing cycles.

E. The method of any one of Paras. A-D, wherein ibudilast or apharmaceutically acceptable salt thereof and the at least one or moreother therapeutic agent are administered for at least six consecutivedosing cycles.

F. The method of any one of Paras. A-E, wherein ibudilast or apharmaceutically acceptable salt thereof and the at least one or moreother therapeutic agent are administered for at least twelve consecutivedosing cycles.

Para. G. The method of any one of Paras. A-F, wherein ibudilast or apharmaceutically acceptable salt thereof and the at least one or moreother therapeutic agent are administered for at least twenty-fourconsecutive dosing cycles.

Para. H. The method of any one of Paras. A-G, wherein ibudilast or apharmaceutically acceptable salt thereof is administered orally.

Para. I. The method of any one of Paras. A-H, wherein ibudilast or apharmaceutically acceptable salt thereof is administered on every day ofthe dosing cycle.

Para. J. The method of any one of Paras. A-I, wherein thetherapeutically effective amount of ibudilast or a pharmaceuticallyacceptable salt thereof is from 0.1 mg to 720 mg per day.

Para. K. The method of any one of Paras. A-I, wherein thetherapeutically effective amount of ibudilast or a pharmaceuticallyacceptable salt thereof is from 30 mg to 200 mg per day.

L. The method of any one of Paras. A-I, wherein the therapeuticallyeffective amount of ibudilast or a pharmaceutically acceptable saltthereof is about 60 mg per day or about 100 mg per day.

Para. M. The method of any one of Paras. A-L, wherein thetherapeutically effective amount of ibudilast or a pharmaceuticallyacceptable salt thereof is administered to the patient over two equaldoses per day.

Para. N. The method of any one of Paras. A-M, wherein the at least oneor more other therapeutic agent is administered at a dosage of 0.1mg/(m²⋅day) to 720 mg/(m²⋅day).

Para. O. The method of any one of Paras. A-M, wherein the at least oneor more other therapeutic agent is administered at a dosage of 50mg/(m²⋅day) to 250 mg/(m²⋅day).

Para. P. The method of any one of Paras. A-M, wherein the at least oneor more other therapeutic agent is administered at a dosage of about 100mg/(m²⋅day), about 150 mg/(m²⋅day) or about 200 mg/(m²⋅day).

Para. Q. The method of Para. A, wherein ibudilast or a pharmaceuticallyacceptable salt thereof and the at least one or more other therapeuticagent are administered for at least two consecutive dosing cycles;

-   -   and wherein the at least one or more other therapeutic agent is        administered at a dosage of about 150 mg/(m²⋅day) during the        first dosing cycle and at a dosage of about 100 mg/(m²⋅day),        about 150 mg/(m²⋅day) or about 200 mg/(m²⋅day) during the second        dosing cycle;    -   and wherein during any subsequent dosing cycles, the at least        one or more other therapeutic agent is administered at a dosage        equal to that of the second dosing cycle.

Para. R. The method of Para. Q, wherein the at least one or more othertherapeutic agent is TMZ and TMZ is administered orally.

Para. S. The method of Para. A, wherein ibudilast or a pharmaceuticallyacceptable salt thereof and the at least one or more other therapeuticagent are administered for at least two consecutive dosing cycleswherein ibudilast is administered at a dosage of about 60 mg per dayduring the first two dosing cycles.

Para. T. The method of any one of Paras. A-S, wherein the glioblastomais classical glioblastoma, proneural glioblastoma, mesenchymalglioblastoma or neural glioblastoma.

Para. U. The method of any one of Paras. A-S, wherein the glioblastomais classical glioblastoma.

Para. V. The method of any one of Paras. A-U, wherein the patient hasextra copies of the epidermal growth factor receptor (EGFR) gene orexpresses abnormally high levels of EGFR.

Para. W. The method of any one of Paras. A-U, wherein the patient lacksheterozygosity in chromosome 10.

Para. X. The method of any one of Paras. A-U, wherein the patientdisplays chromosome 7 amplification.

Para. Y. The method of any one of Paras. A-U, wherein the patient has amutated gene selected from the group consisting of TP53, PDGFRA, IDH1,PTEN and NF1.

Para. Z. The method of any one of Paras. A-U, wherein the patientexpresses NEFL, GABRA1, SYT1 or SLC 12A5.

Para. AA. The method of any one of Paras. A-U, wherein the patientexpresses methylated MGMT.

What is claimed is:
 1. A method of treating a patient diagnosed withglioblastoma or suffering from recurrent glioblastoma comprising:administering to the patient a therapeutically effective amount ofibudilast or a pharmaceutically acceptable salt thereof and at least oneor more other therapeutic agent; wherein the at least one or more othertherapeutic agent is temozolomide (TMZ), carmustine, bevacizumab,procarbazine, hydroxyurea, irinotecan, lomustine, nimotuzumab,sirolimus, mipsagargin, cabozantinib, onartuzumab, patupilone(epothilone B), recombinant oncolytic poliovirus (PVS-RIPO), or anycombination of one or more of the foregoing; wherein ibudilast or apharmaceutically acceptable salt thereof and the at least one or moreother therapeutic agent are administered during an optionally repeatingdosing cycle lasting from about 20 to about 40 days; wherein the atleast one or more other therapeutic agent is administered during onlythe first about 3 to about 7 days of each dosing cycle; and wherein thepatient expresses methylated MGMT.
 2. The method of claim 1, wherein theat least one or more other therapeutic agent is temozolomide (TMZ). 3.The method of claim 1, wherein ibudilast or a pharmaceuticallyacceptable salt thereof and the at least one or more other therapeuticagent are administered for at least three consecutive dosing cycles. 4.The method of claim 1, wherein ibudilast or a pharmaceuticallyacceptable salt thereof is administered orally.
 5. The method of claim1, wherein ibudilast or a pharmaceutically acceptable salt thereof isadministered on every day of the dosing cycle.
 6. The method of claim 1,wherein the therapeutically effective amount of ibudilast or apharmaceutically acceptable salt thereof is from 0.1 mg to 720 mg perday.
 7. The method of claim 1, wherein the therapeutically effectiveamount of ibudilast or a pharmaceutically acceptable salt thereof isadministered to the patient over two equal doses per day.
 8. The methodof claim 1, wherein the at least one or more other therapeutic agent isadministered at a dosage of 0.1 mg/(m²⋅day) to 720 mg/(m²⋅day).
 9. Themethod of claim 1, wherein the at least one or more other therapeuticagent is administered at a dosage of about 100 mg/(m²⋅day), about 150mg/(m²⋅day) or about 200 mg/(m²⋅day).
 10. The method of claim 1, whereinibudilast or a pharmaceutically acceptable salt thereof and the at leastone or more other therapeutic agent are administered for at least twoconsecutive dosing cycles; wherein the at least one or more othertherapeutic agent is administered at a dosage of about 150 mg/(m²⋅day)during the first dosing cycle and at a dosage of about 100 mg/(m²⋅day),about 150 mg/(m²⋅day) or about 200 mg/(m²⋅day) during the second dosingcycle; and wherein during any subsequent dosing cycles, the at least oneor more other therapeutic agent is administered at a dosage equal tothat of the second dosing cycle.
 11. The method of claim 10, wherein theat least one or more other therapeutic agent is TMZ and TMZ isadministered orally.
 12. The method of claim 1, wherein ibudilast or apharmaceutically acceptable salt thereof and the at least one or moreother therapeutic agent are administered for at least two consecutivedosing cycles wherein ibudilast is administered at a dosage of about 60mg per day during the first two dosing cycles.
 13. The method of claim1, wherein the glioblastoma is classical glioblastoma, proneuralglioblastoma, mesenchymal glioblastoma or neural glioblastoma.
 14. Themethod of claim 1, wherein the patient has extra copies of the epidermalgrowth factor receptor (EGFR) gene or expresses abnormally high levelsof EGFR.
 15. The method of claim 1, wherein the patient lacksheterozygosity in chromosome
 10. 16. The method of claim 1, wherein thepatient displays chromosome 7 amplification.
 17. The method of claim 1,wherein the patient has a mutated gene selected from the groupconsisting of TP53, PDGFRA, IDH1, PTEN and NF1.
 18. The method of claim1, wherein the patient expresses NEFL, GABRA1, SYT1 or SLC12A5.